Domestic violence exposure and its long-term effects on children's health

¶ … Exposure to Domestic Violence Effects Children's mental health

When children are faced with violence, adults usually focus on school performance, aggressive behaviors, and anxiety and/or depression, as these are crucial psychological needs following restoration of the child to safety. However, recent research depicts that the less-obvious negative impacts on the physical health of these children are also worrisome and may extend for several years into their future. Domestic violence exposure includes hearing or seeing the events, directly getting involved in the violent situation, or facing the aftermath (such as witnessing maternal depression or physical damage). Nearly 25% of children experience some form of exposure to violence in their juvenile years (Koenen et al. 2010). An in-depth analysis of population-based surveys in developed nations established that 5% to 35% of young children were abused physically, 5% to 30% were abused sexually, and 10% to 20% were witnesses to domestic violence during their childhood years. Subsequent countrywide estimates are in agreement. A United States (U.S.) national survey obtained reports of violence exposure from children aged below 17 years and their parents (Turner, Finklehor and Ormrod, 2010). U.S. estimates for childhood exposures were 7 -- 33% for bodily assault, 20 -- 29% for intimidation, 13 -- 27% for observing domestic violence between adults, 5 -- 19% for physical abuse, 3 -- 11% for sexual assault/abuse, and 2 -- 9% for dating maltreatment. The study was also carried out in the United Kingdom (UK), with estimates being quite similar (Radford et al. 2011). The World Mental Health Survey by the World Health Organization (WHO) presented estimated figures from 21 nations on the basis of retrospective adult-reports concerning their childhood. Of the survey participants, 5-11% recalled being victims to physical abuse, 1 -- 2% reported direct sexual abuse experiences, and 4 -- 8% reported domestic violence exposure (Kessler et al. 2010). The rates vary partly because of differences between girls and boys, younger children and teens, and because of varying approaches to obtaining data and/or definitions across different studies (Moffitt & Grawe, 2013).

For over 20 years, evidence has shown that witnessing domestic violence (DV) can produce post-traumatic stress (PTS) reactions in children who are physically present when such violent acts occur. These children demonstrate serious behavioral and adjustment issues. In light of these findings, one cannot doubt that PTS responses are produced in children due to DV (Tsavoussis, Stawicki, Stoicea, & Papadimos, 2014). Early childhood tribulations have proven to seriously impact mental health. Strains in early life have been linked with cognitive problems such as poor academic performance, low intelligence quotient, poor memory, inattention, poor language proficiency, and lack of reticence. Such problems may plague a person into their adolescence and adult life, as well. Witnessing sexual victimization or DV in childhood years may intensify risks of subsequently getting married to a violent and abusive individual, and cumulative childhood trauma (not trauma in adulthood). As well, the childhood PTS may approximate post-traumatic stress disorder (PTSD) symptoms' complexity among adults (Tsavoussis, Stawicki, Stoicea, & Papadimos, 2014).

Children cannot calm down in intervals of relative peace at home, between episodes of violence, as they are fearful and remain certain that violence will recur. This fear and subsequent recurrence of violence physically impacts children's brain development. Children facing DV exposure all through their lives turn into anxious and scared individuals, who perceive that any and every situation can be violent. They display many PTSD characteristics. Moreover, boys normally mold their own behavior following the perpetrator's example (typically perpetrators are male), while girls mold behavior following their mothers' example, (mothers are generally DV victims) (Zia, 2013).

Several studies have established that child abuse may result in a series of externalizing and internalizing behavior issues. For instance, research has proven that children who are abused can demonstrate depression, anxiety and various other psychological problems. The influence of abuse persists into adolescent age; teens who faced abuse during childhood will more likely suffer internalizing problems like depression. They also tend to display violence perpetration, delinquency, and other externalizing behavior issues (Moylan, Herenkohl, Sousa, Tajima, Herrenkohl, & Russo, 2010).

Literature Review

When children are faced with violence, adults usually focus on school performance, aggressive behaviors, anxiety and depression, as these are crucial psychological needs following restoration of the child to safety. However, recent research depicts that less-obvious negative impacts on the physical health of these children are also worrisome (Shonkoff 2012; Shonkoff et al. 2012). On a national scale, 10% of children are witness to violence between their parents, or inter-parental violence (IPV) (Child Abuse Facts, n.d.; Domestic Violence and Children, n.d.). Studies depict that children often act violently after exposure to IPV. Moreover, when children experience repeated IPV exposure, their ability to differentiate between normal and violent, behavior diminishes greatly (Irish, Kobayashi & Delahanty, 2010). Such children might also attempt to reduce their emotional anguish through internalizing the witnessed behavior. In adulthood, they may actively carry out this internalized behavior, perpetuating intergenerational violence transmission. This transmission is said to take place when adults, exposed in childhood years to violence, behave violently, adversely affecting other children's development and unconsciously intensifying their aggression and IPV after becoming adults (Wood & Sommers, 2011). How children perceive violence affects their idea of a fair world, outlined by the notion that outcomes always restore moral order, thus making it likely that violence will be justified, in their view, as something normal in relationships between adults (Calvete & Orue, 2013). Also, demographic features distinct from domestic setting (i.e. culture, socioeconomic status (SES), gender-specific influence of parents on children, and age) have also proven to have powerful impacts upon violence-witnessing children (Sousa et al., 2011).

Developmental Considerations

DV exposure can have considerable long- and short-term impact on teens and younger children. Such impacts include: increased symptoms of externalizing and internalizing behavior; impacts on physical health, such as diabetes and heart disease; and adverse effects on performance at school. Children hailing from minority backgrounds might be unduly affected by DV exposure because of residing in high-crime and high-poverty localities. This article's purpose is to provide school psychologists with additional knowledge regarding the emotional, academic, and social vulnerabilities accompanying children's DV exposure, and information concerning possible interventions when dealing with traumatized persons (Rhonda & Katie, 2015).

Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) integrates child and parent skill-based elements within a trauma model framework. These elements include: parenting skills (behavior-management abilities); psycho-education (facts on trauma and reaction to trauma); relaxation skills (managing physiological trauma reactions); affective modulation abilities (managing affective trauma responses); trauma accounts and handling (correcting cognitive misrepresentations with regards to trauma, and reorganization of memories); cognitive coping (exploring and discussing relationships between feelings, thoughts, and behaviors); future safety planning; and in vivo control over trauma reminders such as overcoming generalized trauma-related fear (Moffitt & Grawe, 2013). Parents and children are taught these elements in both separate child and parent sessions and in joint parent-child sittings (Moffitt & Grawe, 2013). Twelve to sixteen sessions may be held. TF-CBT seems to lessen general problematic behaviors and PTSD symptoms. Recent TF-CBT studies, yet to be incorporated into reviews or meta-analyses, support the earlier conclusions, while also adding fresh insights. For example, trauma narratives aren't essential for successful treatment; additionally, TF-CBT works for children belonging to different age-groups, beginning from preschool age up until high school. As well, there are more therapies, such as Narrative Exposure Therapy for Children and Adolescents (KID-NET), and Eye Movement Desensitization and Reprocessing (EMDR), for children exposed to violence. These methods are currently in the initial evaluation stages (Moffitt & Grawe, 2013).

Theoretical Approach

Cognitive Behavior Therapy

Little children are subjected to a broad frequency and range of traumatic incidents, putting them in considerable risk of developing PTSD. While evidence-based practices (EBP) to assist these young children have been determined, many times children who require care post-trauma don't receive assistance. The reasons behind this failure to treat young children include stigma, costs, limited accessibility of qualified therapists, and logistical hurdles such as child care, work demands, transportation, and time (Salloum, Scheeringa, Cohen, & Storch, 2014).

A therapeutic approach must be the foremost consideration in the development of a child-centric stepped care model. Specific treatment methods may vary within a single stepped care model; however, there has to be evidence to support the delivered therapeutic techniques. TF-CBT marks the most reputable therapy for childhood-PTSD. CBT to deal with childhood ordeals has proven effective for children from different age-groups and backgrounds, in group and individual settings, and also with children undergoing different kinds of multiple traumatic experiences (Salloum, Scheeringa, Cohen, & Storch, 2014). Moreover, CBT has proven effective with varied trauma symptoms. These include children with or without comorbid illnesses such as anxiety, depression, complex trauma demonstration, and/or behavioral issues, regardless of a complete PTSD diagnosis). Creation of childhood PTSD-centered stepped care models for treating all forms of childhood trauma is vital for numerous reasons, including clinician training, implementation ease, and generalizability (Salloum, Scheeringa, Cohen, & Storch, 2014). Different models adopt different theoretical methods for different stages. EMDR (eye movement desensitization and reprocessing), which is empirically supported as a childhood trauma treatment method, may be Step One, and TF-CBT may be Step Two. However, such an approach necessitates that clinicians be qualified and licensed to carry out two different therapies, thus limiting availability of treatment. CBT is utilized in treating many syndromes and the individual therapeutic methods render CBT flexible to explicit steps. Thus, the most extensively researched individual therapeutic model, CBT, was the approach adopted for Stepped Care Trauma Focused-CBT (Salloum, Scheeringa, Cohen, & Storch, 2014).

Cognitive Processing Theory (CPT)

CPT is a valuable psychotherapy method for treating patients who have suffered trauma. This therapeutic approach was developed in 1992 by Resick and Schnicke and colleagues. It integrates exposure therapy with cognitive skill development/restructuring. CPT has historically been tested among a sample of females who were sexually assaulted. Scholars have confirmed the intervention's effectiveness among diverse traumatized populations, such as incarcerated adolescents, refugees, veterans, and automobile accident victims (Basharpoor, Narimani, Gamari, Abolgasemi, & Molavi, 2011).

The treatment's stages include self-esteem and identity development with simultaneous development of advanced interpersonal relationships and skills. Also, at this point, children often face an existential crossroads linked with a novel sense of self; they have to struggle with their losses and the import of currently-integrated memories of trauma. At this point, survivors often struggle with embracing life with revived hope and energy to face the future. To some, this may mean a commitment towards making a difference to the world, especially with regards to reducing violence, an undertaking termed sometimes as 'survivor's mission'(Courtois, 2014)

The treatment duration and course may differ rather dramatically, with various different treatment approaches being employed across the treatment stages. Some of the children may remain for years in therapy, (particularly those with an insecure style of attachment, and those having the largest trauma histories), never progressing beyond Stage One (Courtois, 2014)

Discussion

Apart from direct interventions for treating child victims, numerous other psychosocial approaches are available to enhance psychosocial adjustment of children in the context of violence exposure, either by working solely with their parents, or working jointly with children and parents. These include interventions for preventing child abuse and reducing violence exposure through providing supervision and education to the parents of very young children. Early Start and Nurse-Family Partnership are two interventions-at-home; these approaches have proven effective. Other interventions at the forefront of reducing child abuse risks through better parenting include Pathways Triple P. And Project Support. Treatments aimed at strengthening parent-infant bonds in households where children at risk of being abused are also prominent. For instance, the family intervention, Project Support provides emotional and instrumental assistance to mothers, teaching child-management to them. It was developed originally for reducing behavior problems among children from households using DV shelters (Moffitt & Grawe, 2013).

Another intervention, Parent-Child Interaction Therapy, caters to the child (exposed to violence) as well as his/her non-offending parent. This method aims at improving parental motivation and skills, and improving child-parent interactions. The intervention achieves this through direct parent coaching and direct skills practice in joint child-parent sittings. Preliminary evidence indicates the importance of an extra module (6 motivational sittings) while working towards child welfare with families wherein children suffer abuse (Moffitt & Grawe, 2013). The triple P. method was assessed through cluster design for randomizing 18 South Carolina (U.S.) counties either to Triple P's program on social learning or a usual-care control condition. Subsequent to intervention, lower numbers of discovered child abuse cases, abuse-linked injuries and hospitalizations, and out-of-home care because of abuse, were observed in counties where Triple P. was adopted. This is the first public parenting intervention that has depicted encouraging population- level impacts on child abuse through randomized sampling, with 'county' being the random assignment unit. Clinical as well as experimental research have proven that well-defined parenting strategies are some of the most effective interventions for promoting child well-being and mental health, especially in households wherein maltreatment risk exists (Moffitt & Grawe, 2013).

Case Material

Currently, I am working with Gabriela, a Latina girl aged 12 years, who hails from a background where inter-parental violence has been observed by her. Recently, the client has begun reporting symptoms of PTSD and anxiety. The client cannot function in social settings and reports self-mutilation because of the impact of interfamilial relationships and family dynamics.

TF-CBT Intervention treatment

Twelve-year-old Gabriela faces constant DV at home. During such episodes, her father afflicts physical violence upon her and her little sister. In the mother's first session, the therapist confirmed the mother's distress, praising her courage in willingly supporting her child during TF-CBT sessions, as she was aware that Gabriela will speak about the domestic violence suffered by her mother; this would be a difficult time for her mother. The mother stated that she wishes to aid her daughter, but they were reliant on the father's earnings for survival (Cohen, Mannarino, & Murray, 2011). The mother's wish to ensure her children's protection from domestic violence was addressed by the therapist; this resulted in brainstorming regarding specific approaches which may be adopted by Gabriela and her mother in protecting the girls. The therapist met with Gabriela and her mother and asked questions to help them both recognize any signs that transpired just before violence occurred. They both asserted that her father overindulged in drink, and at such times, he turned furious and violent (Cohen, Mannarino, & Murray, 2011). They both further asserted that her father's not returning home until 8 PM was 'bad', and indicated that there would be trouble at night when he came home, as he was likely out drinking. Gabriela as well as her mother also stated that in such cases, Gabriela and her younger sister would go next door to her auntie for sleeping. They were asked if mother could also do the same and avoid abuse, but mother claims that this was equally dangerous as, after returning, if the father didn't find anyone home, he would seek them next door. In that case, the young girls would be in danger just as they would if they remained home. Gabriela began implementing the above plan and started feeling safer with time. Though she continued experiencing occasional DV episodes, and was aware that her mother was regularly victimized, she could at least keep herself and her little sister safe. The ability to more effectually protect her girls empowered her mother, as well (Cohen, Mannarino, & Murray, 2011).

Critical Evaluation

The approaches described above were developed in collaboration with community therapists, youths and their parents, and other specialists offering services to families wherein abuse occurs, in two backgrounds. It evaluated TF-CBT effectiveness compared with standard child therapy in a public DV center. This encompassed receiving primary and continuing input from child therapists, child supervisor(s), clinical director(s), and members of the family with regards to TF-CBT implementation for youngsters and their mothers, who faced prior or ongoing violence at home. Additional sessions were conducted between directors, child supervisor, and child therapists in regard to any further modifications required in the model. With continuation of treatment, verbal as well as written input was solicited from mothers. Adapting TF-CBT to constant risk of trauma is still an empirical attempt (Cohen, Mannarino, & Murray, 2011).

TF-CBT designers and trainers, in collaboration with therapists, family members and local community institutions, have formulated practical strategies to apply evidence-based TF-CBT for youngsters and non-offending parents, who face constant trauma (Cohen, Mannarino, & Murray, 2011). The strategies comprise: 1) concentrating promptly and as required, on a continuous basis in the course of therapy, on improving child and parent safety, appropriate for the situational, emotional, and developmental context of the child; 2) improving engagement plans for parents experiencing ongoing exposure to personal trauma; and 3) in the cognitive processing and trauma description stage, focusing on improving parental understanding and support of child's ongoing traumatic experiences; dealing with maladaptive cognitions pertaining to these experiences; and distinguishing between trauma reminders and real threat. By employing these strategies, children and non-offending parents exposed to constant traumas report considerable improvement; this indicates that TF-CBT is a feasible and useful option in handling complex domestic violence cases, wherein risk of violence isn't quickly or easily removed (Cohen, Mannarino, & Murray, 2011).